Oral anticoagulant therapy in patients with mechanical heart valve and intracranial haemorrhage

Abstract

SummaryOptimal timing for restarting anticoagulant therapy after intracranial bleeding is a critical issue. The purpose of this systematic review is to summarize published studies on the management of oral anticoagulant therapy after intracranial bleeding secondary to the use of vitamin K antagonists in patients with a mechanical heart valve. A computer-assisted search of the MEDLINE and EMBASE electronic databases till January 2008 was performed. Two investigators independently performed study selection and completed a predefined quality assessment and data extraction form. Main inclusion criterion was the enrolment of patients with a mechanical heart valve and intracranial haemorrhage during oral anticoagulant treatment. Any randomised controlled trial, observational cohort study, case series and reports was included. No randomised controlled trials were identified. Six observational cohort studies were included in the final analysis. All studies were of low quality. A total of 120 patients were enrolled. Anticoagulation was restarted within a broad time range (2 days to 3 months). Four ischaemic strokes and two recurrent cerebral haemorrhages occurred after anticoagulation was restarted after a mean follow-up of 7.9 months. Eighteen patients were described in the selected case reports. Anticoagulant therapy was restarted within four days to eight weeks. Two patients had a recurrent haemorrhagic event, and no ischaemic events were reported. In conclusion, restarting oral anticoagulant therapy few days and, indirectly, stopping anticoagulant therapy for a few days (even for 7–14 days) after the occurrence of cerebral haemorrhage are both safe. However, well-designed studies are strongly recommended to provide better evidence.

Optimal Timing of Resumption of Warfarin After Intracranial Hemorrhage

“…Resumption occurred after a median of 4.4 weeks (IQR 2. [3][4][5][6][7][8][9][10][11][12][13][14] in patients with intracerebral hemorrhage, compared with 6.4 weeks (IQR 3.6 -26) after subdural hematoma.…”

“…A recent systematic review of studies in patients with mechanical heart valves reached the same conclusion based on only 2 recurrent hemorrhages and 4 strokes. 14 Seven experts expressed the opinion that warfarin could be restarted in stable patients 3 to 10 days after intracranial hemorrhage. 15 We performed this study to address the timing of resumption of warfarin after intracranial hemorrhage and assess the risks and benefits both in patients who restarted warfarin and those who did not.…”

Resumption of Oral Anticoagulation After Warfarin-Associated Intracerebral Hemorrhage

“…Currently available data are contradictory. A review of 6 observational studies on oral anticoagulation in patients with mechanical valves concluded that restarting oral anticoagulation after 7 to 14 days appeared safe 6 ; however, a delay of reintroduction of warfarin until between 10 and 30 weeks has also been suggested. 2 Nevertheless, all studies, however, present a similar pattern: the probability of ICH recurrence is highest during the early phase after the index bleeding and decreases over time, whereas risk of ischemic events increases over time and will cross at some point in time.…”

Resumption of Oral Anticoagulation After Warfarin-Associated Intracerebral Hemorrhage

“…Until recently, expert opinion 1 as well as systematic reviews 2,3 were favoring early resumption, that is, after 3 to 14 days, of anticoagulation in stable patients. A retrospective study of 234 patients with warfarin-associated ICH concluded that the resumption should be delayed by 10 to 30 weeks to avoid the early high-risk period for recurrent hemorrhage, during which full anticoagulation appeared to increase this risk 5-fold.…”

“…До недавнего времени мнение экспертов [1], а также данные систематических обзоров [2,3] свидетельство-вали в пользу скорейшего возобновления антикоагу-лянтной терапии у стабильных пациентов, т.е. через 3-14 дней.…”